Just How Often Do Patients Turn Post-Surgical Opioids Into a Habit?

More studies suggest surgeons are too liberal with scripts

by John Gever John Gever,Managing Editor, MedPage Today
December 31, 2017

Last May, researchers at Johns Hopkins University presented results of an internal study showing that most orthopedic surgery patients didn't take all the opioid pills they were given at discharge, nor were many told what to do with unused pills. Click here to read our original report on the study. In this follow-up, we look at additional research on this topic appearing since then.

As 2017 rolled on, more research as well as anecdotal contributions suggested that opioid prescribing after surgery is a reason the nation appears to be awash in the drugs, and their abuse.

The Hopkins group, led by Mark Bicket, MD, followed up on the May presentation with a meta-analysis published in August that pulled together results from six studies by other groups. It confirmed the group's experience in their own center: from 42% to 71% of pills dispensed at discharge were never used.

In November, Kaiser Health News reporter Michelle Andrews shared her own experience, in which her surgeon prescribed 90 oxycodone/acetaminophen (Percocet) tablets after what she termed a minor laparoscopic knee surgery. When she asked her surgeon why so many, he said it was the default in his hospital's ordering system for knee procedures. "If you had real surgery, like a knee replacement, you wouldn't think [90] was so many," she quoted him as saying.

Andrews didn't say what she had done with her unused pills, but Bicket's group said safe disposal is uncommon. People who do want to get rid of them usually throw them in the trash or flush them down the toilet, but it's just as common, if not more so, to hoard them for some future pain episode. Or give them to friends and relatives who complain of pain.

Still another study, published in December in JAMA Surgery by a group in Boston, found a high rate of "potential overprescription:" patients discharged with opioid prescriptions even though they hadn't received any opioids during their last 24 hours as inpatients. More than 40% of patients who were opioid-free at discharge in the study still went home with prescriptions.

A key question is whether, and how often, patients turn their post-surgical opioid prescription into a long-term habit. A study appearing in JAMA Surgery on June 21 gave an unwelcome answer: yes, they do, at a rate of about one in 16.

The study examined claims data involving some 36,000 surgical patients. The likelihood of persistent use beyond the first 90 days was not affected by whether the surgery was deemed major or minor. Instead, risk factors included comorbid substance use (including alcohol, tobacco, and other drugs), mood disorders, and pre-surgical pain diagnoses.

"This suggests [persistent opioid] use is not due to surgical pain but addressable patient-level predictors," wrote the authors, led by Chad Brummett, MD, of the University of Michigan in Ann Arbor.

Earlier studies had reached similar conclusions. In 2016, a paper in JAMA Internal Medicine, also drawing on claims data, found that previously opioid-naive surgical patients were at increased risk of long-term opioid use (defined as more than a 120-day supply or 1o consecutive prescriptions), compared with nonsurgical patients without previous history of opioid prescriptions.

And in 2013, researchers presenting at the North American Spine Society reported that about one-third of patients undergoing back surgery were still taking opioids a year later. About half of those on opioids prior to surgery were still using them, as were 18% of those without a prior opioid history.

One obvious approach to minimizing risk that post-surgical opioid prescriptions will lead to addiction is to use non-opioid painkillers instead. NSAIDs sometimes have been proposed but are largely viewed as inadequate for this purpose.

Another suggestion has been gabapentin, and it was the subject of a clinical trial reported just 2 weeks ago. It enrolled patients undergoing a variety of orthopedic surgeries (open and laparoscopic) and mastectomy and randomized them to receive gabapentin or placebo, both pre- and post-operatively, in addition to post-op opioids. Those assigned to gabapentin stopped opioid use after a mean of 25 days versus 32 days for the placebo group.

The authors said gabapentin had "a modest effect on promoting opioid cessation after surgery." (Unclear, though, was whether patients were still sent home with 90 Percocets.)

Another view of the relationship between in-hospital opioids and subsequent long-term use came from Suneel Kamath, MD, a hematology/oncology fellow in Chicago's Northwestern Memorial Hospital. In a poignant personal recollection written for MedPage Today, he suggested that simply wanting to be liked may influence hospital physicians to prescribe opioids for patients who ask.

He noted as well that refusing a patient's request often leads to a discussion, and sometimes a time-consuming and uncomfortable one. "I have to believe that at some point in residency, I gave a patient opioids to avoid the emotional toll of the conflict and to move on more quickly to my other patients. I suspect I am not alone."

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